2018;26e2968
DOI: 10.1590/1518-8345.2099.2968 www.eerp.usp.br/rlae
Cross-cultural validation of the Child Adolescent Teasing Scale for
Colombian students
Objective: to carry out the cross-cultural validation of the instrument “Child Adolescent Teasing
Scale” for the Colombian student population. Method: methodological study carried out with
students aged 8 to 15, from public and private educational institutions in the municipality of
Ibagué, Colombia. The form for the characterization of students and the Child Adolescent Teasing
Scale were used. Results: the cross-cultural adaptation process was organized in seven steps:
comparison of the Spanish version of the instrument with the original English version,
back-translation, consensus version, face validity and terminology adjustment by students, face and
content validity by experts, assessment committee for the final version, pilot test and reliability.
Conclusion: the version adapted to the Spanish spoken in Colombia of the Child Adolescent Teasing
Scale (Escala de burlas para niños y adolescentes), which assesses the frequency and distress
caused by teasing, showed desirable results in terms of validity and reliability.
Descriptors: Bullying; Validation Studies; Surveys and Questionnaires; School Nursing; Nursing;
Nursing Methodology Research.
How to cite this article
Briñez Ariza KJ, Caro Castillo CV, Echevarria-Guanilo ME, Do Prado ML, Kempfer SS. Cross-cultural validation
of the Child Adolescent Teasing Scale for Colombian students. Rev. Latino-Am. Enfermagem. 2018;26e2968.
[Access ___ __ ____]; Available in: ___________________ . DOI: http://dx.doi.org/10.1590/1518-8345.2099.2968
year day
month URL
Karol Johanna Briñez Ariza
1Clara Virginia Caro Castillo
2María Elena Echevarría-Guanilo
3Marta Lenise Do Prado
4Silvana Silveira Kempfer
51 MSc, Nursing. Doctor Degree Student, Nursing, Universidad Nacional de Colombia, Bogotá, Bog, Colombia. Researcher. Doctor Degree
Sponsorship: Beca Colciencias Colombia para el Doctorado en Enfermeria.
2 PhD. Full Professor, Nursing, Universidad Nacional de Colombia, Bogotá, Bog, Colombia. 3 PhD, Nursing. Professor, Nursing, Universidad Federal de Santa Catarina, Florianopolis, SC, Brazil.
Introduction
Research in pediatric and adolescent nursing
seeks to deepen the knowledge of phenomena related
to health care by promoting studies that fill the gaps identified in the scientific literature and that aim to
contribute to: new perspectives and alternatives for
the resolution of problems affecting their health and
welfare, as well as the welfare of their family.
One of the most prevalent phenomena in today’s
society, first described more than three decades ago, is the bullying among students. It is defined as the
exposure of a student to the repetitive negative actions
by another or more students, or difference in power,
with the intent to cause damage or discomfort through
words, physical contact or other forms, such as gestures,
exclusion and defamation(1-2).
The American National Association of School Nurses
defines bullying as persistent and repetitive dynamic
patterns of verbal and/or nonverbal behaviors directed
by one child or more children to another, who deliberately
attempt to cause physical, verbal or emotional abuse in
the presence of actual or perceived difference in power(3).
It has been associated with a number of damages
and consequences for the health of children and
adolescents, and has become internationally recognized
as a public health problem(4).
The problem mentioned above has negative
consequences for victims, such as inability to defend
themselves, powerlessness, sadness, crying, fear, loss
of concentration and suicidal ideation(5). Depression,
anxiety and low self-esteem affect normal development
in learning processes and their integration and adaptation
in the school setting(6). Association between bullying
and different variables: Depression (p<0.01)(7)
, sleep
problems (p<0.05), nervousness (p<0.05), restlessness
(p<0.05), feelings of discomfort (p<0.05) and dizziness
(p<0.05)(8). Psychosomatic disorders in victims
(p=0.0001)(9). Physical injuries (p<0.001), symptoms of
illness (p<0.001) and somatic complaints (p<0.001)(10).
Chromosomal changes in the telomeres (p=0.020), which
are biomarkers of childhood stress and cell aging(11).
According to this scenario, it is necessary to
implement strategies through assessment methods for the
early identification of students who experience teasing,
because of their risk of becoming victims of bullying.
There are several instruments, such as the
Questionnaire for the Ombudsman’s report on school
violence(12) and the “Bullying-Cali”(13), used for older
schoolchildren.
Many of the instruments originally available were
published in languages other than Spanish, which
requires for the study in the Colombian context that the
instruments be submitted to the processes of cultural
adaptation, through the development of the translation
and validation stages(14). Thus, the instrument can be
used in a different culture from which it was developed.
In this way, an instrument that could be used for
students from the age of eight and that assessed the
causes of teasing in all risk categories was searched,
and these criteria have been met by the Child Adolescent
Teasing Scale(15).
For the reasons described above, this study aimed
to answer the question: What is the validity of the Child
Adolescent Teasing Scale for the Colombian student
population? It has been proposed in order to: determine
the validity of the Child Adolescent Teasing Scale for the
Colombian student population.
Method
This is a methodological study developed with
students aged from 8 to 15, from public and private
educational institutions in the municipality of Ibagué,
Tolima (Colombia). Inclusion criteria: belong to the
grades between the third grade of elementary school
and the eighth grade of secondary school, and present
the authorization signed by their parents.
Description of the instruments. Two instruments
were applied: The form for the characterization of
students and the Child Adolescent Teasing Scale.
Form for the characterization of students
Developed by the main author, it asked about
variables such as sex, age, grade, type of educational
institution; it was applied during the stages of meeting
with the students: focal groups for the version by
students and pilot test.
The Child Adolescent Teasing Scale (CATS)
It is composed of 32 items and assesses four teasing
categories: physical aspect (items 11 and 21), personality
and behavior (items 1, 3, 6, 7, 8, 12, 16, 20, 22, 24, 26,
27, family and home environment (items 2, 9, 10, 17,
19, 25, 29), and school-related factors (items 4, 5, 13,
14, 15, 18, 23, 28, 32). These categories are organized
into two subscales: frequency and distress. The frequency
item is assessed on a Likert-type scale, with the following
response options: never (1) sometimes (2) often (3) and
very often (4). The distress subscale assesses how much
it bothers to be teased, and each item is assessed on a
Likert-type scale, with the following response options: not
at all (1), very little (2), more or less (3), very much (4).
This scale scores values ranging from 32 to 128 for each
subscale and from 64 to 256 for the full scale. The higher
the value, the greater the teasing experienced by children
and adolescents at school.
Cross-cultural adaptation process
The cross-cultural adaptation process was
organized into seven stages(14): Comparison of the
Spanish version of CATS with the original English version,
back-translation, consensus version, face validity and
terminology adjustment by students, face and content
validity by experts, assessment committee for the final version, pilot test and reliability (see figure 1).
Comparison of the Spanish version of CATS with
the original English version. The author received the
authorization, the original English version and a Spanish
version, which was translated by her for Mexico and
Puerto Rico. The objective was to make the necessary
adjustments of CATS to the Spanish spoken in Colombia.
Words and sentences were compared. A nurse with a
good command of the English and Spanish languages
and expertise in the validation of assessment instruments
participated in this stage (CATS-VECO).
Cross-cultural adaptation of the Child Adolescent Teasing Scale for Colombian studentes
1. Comparision by expert nurse Spanish version/English version
2. Back-translation of CATS into English
3. Spanish version initial consensus
5. Face and content validity by experts. English version by experts
7. Pilot-reliabity test 6. Spanish version final consensus 4. Face validity and terminology adjustment by students.
Spanish version by students
CATS-VECO
CATS-RI
CATS-VECI
CATS-VEES
CATS-VEEX
CATS-VECF
Figure 1 – Process of cross-cultural adaptation of CATS to the Spanish spoken in Colombia, 2015-2016
Back-translation. The objective was to translate the
version resulting from the first stage into the original
language of the instrument. This procedure was carried
out by an English native speaker translator who
back-translated it from Spanish into English (CATS-RI).
Initial consensus version (CATS-VECI). The objective
was to define a version for students that included the
adjustments recommended in the two previous stages
(CATS-VECO and CATS-RI). It was achieved through a
meeting between the supervisor of the doctoral thesis,
the principal researcher and the nurse who participated
in the first stage for the consensus version.
Face validity and terminology adjustment by students.
The objective was to get the verbal manifestations of “how
students aged 8 to 10 spoke and said those phrases” in
their everyday Colombian language, so that the scale could
be understood by older students. This was accomplished
through a qualitative strategy according to the target
population, through five focal groups and by presenting
transitional and key questions were applied. It was
concluded with refreshments served to the participants and
feedback. Audio recording and transcription were performed
for analysis. Changes were made and the modified version
was proposed (CATS-VEES).
Face and content validity by experts. The objective
was to get the assessment of CATS by six experts from
Colombian Universities with experience in adapting
assessment instruments, professional experience and
experience in pediatric research and bullying. Each
expert completed the “expert judgment” form(16),
which contained a consent for its use, and assessed five categories regarding content validity: semantic
equivalence, clarity, consistency, relevance and adequacy with scores ranging from 1 (does not fulfill its function) to 4 (high level of qualification). As for face
validity, the writing, precision and clarity of language of
each item were evaluated, with a score of 0 (does not fulfill) and 1 (fulfill). This has allowed for suggestions that resulted in a modified version (CATS-VEEX).
Final consensus version (CATS-VECF). The objective
was to make the decisions for the adjustment of the items, according to the suggestions made in the fourth and fifth
stages. Consensus was reached by a committee composed
of the main researcher, the supervisor of the thesis due to
her professional experience with students, and a statistician
who performed and interpreted the Kappa statistical test.
The interpretation of the results of Kappa test was based
on a theoretical reference(17), where the strength of the
Kappa coefficient is as follows: poor (0.00); slight
(0.01-0.20); fair (0.21-0.40); moderate (0.41-0.60); substantial
(0.61-0.80); almost perfect (0.81-1.00).
Pilot test. The objective was to check the
understandability of the items and instructions for
completing the instruments, calculation of completing
time, need for help, and materials to make the pertinent modifications and corrections. The main researcher and
the research assistant provided a CATS scale and a black
pen for each student, which was positioned in a separate
and individual place. For reliability, Cronbach’s alpha was
calculated. Values higher than 0.50 were considered as
high (possible variation from 0 to 1)(18).
Ethical considerations
According to Resolution 8430 of 1993 of the Colombian
Ministry of Health, this research was considered to be
of minimal risk. The Ethical Committee of the Faculty of
Nursing of the National University of Colombia approved the
study, and authorization to perform it was obtained from the
Health and Education Secretariat of Ibagué. Authorizations
were requested to the parents of the students through
informed consent, and to the students through an informed
consent, and authorizations were also requested to the
professionals to participate.
Results
Comparison of the Spanish version of CATS
The original English version was compared with the
Spanish version, generating a version for students
(CATS-VECO). The adjustments were made in the instructions
and statements that contained the words “to bother” and
“to annoy”; which were replaced by “to tease”, the word
most used in Colombia. The terminology was considered
understandable, however, it was considered important
that the instrument was submitted to face validity by
Colombian students.
Face and content validity by students
The focal groups consisted of 42 students aged
8 to 10, from the third grade of elementary school of
a public educational institution in Bogotá, with low
socioeconomic status, of which 11 were female and 14
male; and of a private educational institution of Ibagué,
with high socioeconomic status, of which nine were
female and eight were male.
The 32 items (CATS-VECO) were presented to the
students and adjusted to their language according to their
everyday speech. The proposals by the focal group were
put to the vote, and during the discussion, they decided
which phrase was the clearest and most appropriate. The
statements of eight items were not changed because they
were easily understood. All the words in the statements of
eight other items had to be replaced by synonyms most
commonly used in Colombia (Table 1).
The remaining 16 items required adjustment of
the words in the statements, resulting in a different
and more updated wording, or the addition of a word
suggested as a synonym, or adjustments to indicate
that it was related to something specific. The
Table 1 – Change of all 8-item words of the Spanish version of CATS*, Bogotá and Ibagué, Colombia, 2015-2016
Item # Version items (CATS-VECI†) Items changed by students (CATS-VEES‡)
2 My money Being rich or poor
4 My qualifications My grades
5 Talking too much To talk or chat a lot in class
8 My behavior My way of being
11 The shape of my body Some aspect of my body
17 My jewels/chains My ornaments or accessories
28 My school work My school tasks
29 My progenitors My parents
*CATS: Child Adolescent Teasing Scale. †CATS-VECI: Spanish version initial consensus. ‡CATS-VEES: Spanish version by students.
Table 2 – Adjustments suggested by students of some words in the 16 statements of the items of CATS*. Bogotá and
Ibagué, Colombia, 2015-2016
Item # Version item (CATS-VECI†)
Items changed by students (CATS-VEES‡) Item #
Version item (CATS-VECI†)
Items changed by students (CATS-VEES‡)
3 “How intelligent and prepared I am”
“How intelligent I am”; 20 “For being studious” “For being a nerd or studious”
9 “The brand of shoes
that I use” “The brand of my shoes” 22 “For being a coward” “For being a coward or a chicken”
10 “With whom I live” “People that I live with”; 23 “How well I do at school” “How well I do in the studies”
12 “Behave myself
strangely or differently” “Behave myself differently”
25 “My things” “My things or personal items”
14 “My way of speaking” “My way to speak” 25 “Be a fool” “They tell me that I am a fool or a
loser”
15 “Get in trouble” “Get into a tight spot” 27 “Be shy or too quiet” “Be shy or quiet”
16 “Behave myself as gay” “They tell me that I am gay or lesbian”
30 “The music that I like to
listen to” “The music that I like”
19 “How my family is “My family” 32 “Sports I participate in and
do not participate in” those that I do not practice or play”“Sports that I practice or play and
*CATS: Child Adolescent Teasing Scale. †CATS-VECI: Spanish version initial consensus. ‡CATS-VEES: Spanish version by students.
Validity by experts
The CATS-VECO and CATS-VEES versions
were provided to the selected experts. Among the
assessments, three items required clarity and wording
adjustment: from “too much talking” to too much
talk, “my jewels/chains” to my accessories and “get in
trouble” to get into a tight spot. Three items were not
clear to the experts, but to students, “Not being good at
sports” “Shy or quiet” and “Having strange or different
friends”. The experts approved the 16 items changed in
the wording by students.
The Kappa index showed substantial agreement
for the indicators: semantic equivalence: 0.72, clarity
0.65, consistency 0.71, relevance 0.79; and moderate
agreement in the adequacy indicator: 0.56. Regarding
face validity, the agreement percentage among experts
was calculated and showed that 84.9% of the items
complied with the wording, accuracy and clarity in
relation to the language. Based on these results, the
CATS-VEEX version was proposed.
Final consensus version
The necessary adjustments were made after
identifying the items that were recognized by students
as semantically different, but that did not alter their
conceptual equivalence. In addition, the items were
compared with the assessments made by experts in
order to proceed the necessary adjustments of CATS,
which would be used in the main study. No items were
removed. The CATS-VECF version was proposed.
Pilot test
In this process, 19 students aged 11 to 13,
from the sixth grade of elementary school of a private
educational institution of Ibagué, with medium
male, participated. The understandability of the items
and the ease of completion by students was confirmed
and the time spent for completing it ranged from 10 to
15 minutes. In this stage, the reliability of the scale was
calculated using the Cronbach’s alpha, with a result of
0.89 for the frequency subscale, 0.95 for the distress
subscale, and 0.95 for the full scale. These values were
considered as high(18).
Discussion
Nursing is a discipline called to work on the
phenomenon of teasing and bullying, as stated by the
National Association of School Nurses of the United
States(19). It plays an important and decisive role in
the early identification and implementation of bullying
prevention strategies by screening the cases with this
kind of problem and, therefore, helping to promote the
health of students and their families.
Scientific literature describes several instruments
used in research, but few with validity and reliability.
For this reason, the cross-cultural adaptation of a
nursing measurement instrument was carried out, which
measures the frequency of teasing and how much it
bothers the student who receives it, and an appropriate
methodological quality has been demonstrated(20-22).
In the process of cross-cultural adaptation of CATS, a scientific and suggested methodology was
used to ensure the comparability between the results of
Colombian students and those of previous versions(14,22).
The qualitative strategy with the focal groups was
fundamental to achieve, among the Colombian students
aged 8 to 10 years, with different socioeconomic status
and type of educational institution, the understandability
of CATS by older students. For this reason, the age
interval for application of the instrument was enlarged,
ranging from 8 to 15 years in the present study.
It is important to mention that the experts qualified
three items of the face validity as unclear or with
inappropriate wording; however, these items were clearly
understood by students. The above refers to the value
that the participation of a group of students similar to
the group that will be investigated has, providing validity
to the results and compliance with the requirements for
an ethical research with children, avoiding biases due to
the perspective of adults.
The validity by experts provided a perspective from the point of view of a researcher with scientific
knowledge, and from a professional with practical
care experience and ability with students, which has
contributed significantly considering different points
of view and lines of thought. This process has been
shown to be important in achieving understandability
and cultural coherence in the search for semantic and
content equivalence(23-24).
The suggested adjustments were related to the
wording of the items and to the observations that were
analyzed from the students’ point of view, as an interface
between two visions. The importance of the participation
of these groups for the validation of scales is confirmed
by references in the literature(25).
The psychometric tests used in this study show
the high level of consistency of the results of the Child
Adolescent Teasing Scale (CATS) due to its reliability. The
interpretation of the results of the two subscales showed
that they were classified as high, indicating that the
assessment provided by this scale is reliable. In terms of
validity, the Kappa coefficient for the semantic equivalence,
clarity, consistency and relevance ranged from 0.61 to
0.80, indicating a substantial agreement, and the adequacy
showed a moderate agreement, ranging from 0.41 to 0.60,
which allowed to conclude that the proportion of times that
the evaluators agreed was high(26-27).
As limitations, some authors mention the need to
start from the official translation of the original version.
For this, the Spanish version of the instrument provided
by the author was submitted to different validity
and adaptation processes, such as back-translation,
assessment by an expert nurse, validity by students and
validity by experts. In addition, it was compared with
the original English version.
Although the objective of this study was to carry out
a qualitative assessment in terms of understandability of
the items by representatives of the same population to
which CATS would be applied, the Cronbach’s alpha was
calculated to achieve reliability, clarifying that due to the
small sample size, additional studies could support the
psychometric properties of CATS.
Regarding the number of subjects in the pilot
sample, there are different opinions, some suggest 30
to 40 people(14), or 5 to 10 people(22), because the most
important is to achieve understandability on: questions
and answers, format of the applied instrument, or
problems of the questionnaire(28). This study was carried
out with 19 students, a group that can be an important
sample to check the clarity, feasibility and practicality of
the instrument. However, further publications will present
With regard to the phenomenon of school bullying,
so widespread, health professionals are advised to
perform an interdisciplinary work, since the ultimate
goal is the health of students; and the implementation
of actions to identify children at risk of bullying, who
require care in relation to their health.
Conclusion
The cross-cultural adaptation of the Nursing
Instrument Child Adolescent Teasing Scale (CATS)
for its application in Colombian students aged 8 to
15 was carried out. This version was adapted to the
Spanish spoken in Colombia, with the participation
of students, by means of the focal group strategy,
as well as a pilot test. The participants had high
and low socioeconomic statuses, and experts in
research on bullying also participated in this study.
The adapted version showed desirable results in terms
of validity and reliability, which make it possible to point
out CATS as a valid and reliable instrument to be applied
among students with the aim of identifying the frequency
and distress caused by bullying, and it is available for
use in future investigations.
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Received: Jun 06th 2017 Accepted: Sep 22th 2017
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Corresponding Author: Karol Johanna Briñez Ariza Universidad Nacional de Colombia Edificio nuevo de la Facultad de Enfermeria Av. Carrera 30 No. 45-03
Ciudad Universitaria - Edificio nuevo de Enfermeria Oficina 305-306. Bogota, Colombia.
E-mail: kjbrineza@unal.edu.co
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